Patterns of inhaled asthma medication use: a 3-year longitudinal analysis of prescription claims data from British Columbia, Canada

Expert Opinion on Practice Patterns in Mild Asthma After the GINA 2019 Updates: A Major Shift in Treatment Paradigms from a Long-Standing SABA-Only Approach to a Risk Reduction-Based Strategy with the Use of Symptom-Driven (As-Needed) Low-Dose ICS/LABA

PURPOSE OF REVIEW

This expert opinion, prepared by a panel of chest disease specialists, aims to review the current knowledge on practice patterns in real-life management of mild asthma and to address the relevant updates in asthma treatment by The Global Initiative for Asthma (GINA) to guide clinicians for the best clinical practice in applying these new treatment paradigms.

RECENT FINDINGS

On the basis of the emerging body of evidence suggesting the non-safety of short-acting β2-agonists (SABA)-only therapy and comparable efficacy of the as-needed inhaled corticosteroids (ICS)-formoterol combinations with maintenance ICS regimens, GINA recently released their updated Global Strategy for Asthma Management and Prevention Guide (2019). The new GINA 2019 recommendations no longer support the SABA-only therapy in mild asthma but instead includes new off-label recommendations such as symptom-driven (as-needed) low-dose ICS-formoterol and "low dose ICS taken whenever SABA is taken." The GINA 2019 asthma treatment recommendations include a major shift from long-standing approach of clinical practice regarding the use of symptom-driven SABA treatment alone in the management of mild asthma. This expert opinion supports the transition from a long-standing SABA-only approach to a risk reduction-based strategy, with the use of symptom-driven (as-needed) low-dose ICS/LABA in mild asthma patients, particularly in those with poor adherence to controller medications. The thoughtful and comprehensive approach of clinicians to these strategies is important, given that the exact far-reaching impact of this major change in management of mild asthma in the real-world settings will only be clarified over time.

Over-prescription of short-acting beta agonists in the treatment of asthma

BACKGROUND

Despite a clear guideline for asthma medication, excessive use of short-acting β2-agonists (SABAs) is common in clinical practice. Previous research has shown that excessive use of SABAs is associated with poor asthma control.

OBJECTIVE

This study examines current use of asthma medication in primary care and whether excessive use of SABAs is associated with exacerbations.

METHODS

The study design was a retrospective analysis using information from electronical medical records from patients aged 18 and older of five Julius Health Centers located in Utrecht, the Netherlands, in the period of 1 July 2018 through 1 July 2019. Excessive SABA use was defined as ≥400 inhalations per year. An exacerbation was defined as an acute worsening of asthma symptoms with the need for systemic corticosteroids.

RESULTS

A total of 1161 patients were included in the study. Of the patients using SABAs (n = 766), 193 (25%) overused SABAs. Among the patients with inappropriate SABA use (n = 193), 19% had an exacerbation compared with 7% of the appropriate SABA users. For patients using asthma medication the odds of having an exacerbation were 2.9 times higher if they used an inappropriate number of SABAs than if SABAs were used appropriately (odds ratio, 2.897; 95% confidence interval, 1.87-4.48).

CONCLUSIONS

This study shows that overuse of SABAs is still common and that it is associated with asthma exacerbations. It highlights that clinicians need to be aware of inappropriate SABA use as it is a sign of and can even contribute to poor asthma control.

Real-world patterns and implications of short-acting β2-agonist use in patients with asthma in the United States

BACKGROUND

Short-acting β₂-agonist (SABA) use is one measure reflecting asthma control.

OBJECTIVE

To evaluate the associations between real-world SABA use and severe asthma exacerbations in the United States.

METHODS

Patients with asthma 12 years of age or older receiving SABA in the IBM MarketScan research databases of US administrative claims from September 30, 2014, to September 30, 2016, were evaluated. Patients with 12 months' continuous eligibility before and after their first SABA claim (index SABA), an asthma diagnosis before through 60 days postindex, and either one additional SABA or at least 1 maintenance fill(s) were included. SABA claims postindex (including index fill) were grouped as follows: low: index only; medium: 2 to 3 canisters per year; and high: 4 or more canisters per year. Differences in SABA exposure with respect to disease severity groups and severe asthma exacerbations (hospitalizations, emergency visits, or outpatient systemic corticosteroids) were analyzed by analysis of variance and χ² (significance, P ≤ .05).

RESULTS

A total of 135,540 patients were included: 62.8% women; mean (SD) age, 40.9 (18.3) years; SABA fills per 12-months postindex: 3.0(2.7). Furthermore, 28% of patients filled 1 SABA, 47% 2 to 3, and 25% 4 or more canisters per year. Despite higher maintenance medication possession ratio with increasing SABA (low, 0.53 (0.37); medium, 0.59 (0.35); high, 0.66 (0.32)), annual exacerbation rate per person per year and percent of patients within each SABA group having at least 1 exacerbation rose as SABA fills increased (low, 1.00 (1.45), 45.8%; medium, 1.20 (1.62), 54.3%; high, 1.50 (1.94), 58.7%). Mean SABA fills differed between patients with 0 exacerbation, 2.8 (2.6); 1 exacerbation, 2.9 (2.5); and 2 or more exacerbations, 3.3 (2.9).

CONCLUSION

Exacerbation risk increased with increasing SABA fills. Management strategies ensuring adequate anti-inflammatory therapy delivered to the airways when symptoms occur may be needed to mitigate asthma morbidity.

[Association between the use of short-acting bronchodilators and the risk of hospitalization for asthma in a real-life clinical practice population cohort]

Objetivo

Determinar la cantidad de envases de broncodilatadores de corta duración (SABA) dispensados en farmacia en un año que se asocia con mayor riesgo de hospitalización por asma en el mismo periodo en pacientes con asma activa. Diseño descriptivo transversal multicéntrico.

Emplazamiento

Atención primaria, cohorte MAJORICA. Incluye datos codificados durante la práctica asistencial, sociodemográficos, clínicos y del sistema de prescripción electrónica de 68.578 pacientes con EPOC y asma de Baleares.

Participantes

Se incluyeron 7.648 pacientes mayores de 18 años con asma activa, que retiraron envases de SABA durante el periodo 2014-2015. Se excluyeron pacientes con EPOC.

Mediciones principales

Hospitalización por asma, utilización de fármacos respiratorios, tabaquismo, comorbilidades, edad y sexo.

Resultados

Edad promedio 47 años, 38% mujeres, 23,2% fumadores activos. Setenta y siete pacientes (1%) ingresaron por exacerbación de asma en el periodo de estudio. Los pacientes que recibieron más de 8 envases de SABA por año aumentaron el riesgo de hospitalización (OR 2,81; IC95% 1,27-6,24). El escalón terapéutico de gravedad, la cantidad de corticoides inhalados, así como la insuficiencia cardíaca y la apnea del sueño se asociaron también significativamente con la hospitalización.

Conclusiones

Un mayor escalón terapéutico de gravedad, la presencia de algunas comorbilidades, el consumo de mayor cantidad de corticoides inhalados y de un mayor número de envases de SABA identifica a asmáticos con mayor riesgo de hospitalización. Existe una asociación significativa entre el riesgo de hospitalización y la retirada de un mayor número de envases de SABA de la farmacia. El número de envases/año que mejor define un mayor riesgo de hospitalización es ≥ 8 y se podría utilizar para identificar asmáticos de riesgo.

Predictors of inappropriate and excessive use of reliever medications in asthma: a 16-year population-based study

BACKGROUND

Understanding factors associated with the inappropriate or excessive use of short-acting beta agonists (SABA) can help develop better policies.

METHODS

We used British Columbian (BC)'s administrative health data (1997-2014) to create a retrospective cohort of asthma patients aged between 14 and 55 years. The primary and secondary outcomes were, respectively, inappropriate and excessive use of SABA based on a previously validated definition. Exposures were categorised into groups comprising socio-demographic variables, indicators of type and quality of asthma care, and burden of comorbid conditions.

RESULTS

343,520 individuals (56.3% female, average age 30.5) satisfied the asthma case definition, contributing 2.6 million person-years. 7.3% of person-years were categorised as inappropriate SABA use and 0.9% as excessive use. Several factors were associated with lower likelihood of inappropriate use, including female sex, higher socio-economic status, higher continuity of care, having received pulmonary function test in the previous year, visited a specialist in the previous year, and the use of inhaled corticosteroids in the previous year. An asthma-related outpatient visit to a general practitioner in the previous year was associated with a higher likelihood of inappropriate SABA use. Similar associations were found for excessive SABA use with the exception that visit to respirologist and the use of systemic corticosteroids were associated with increased likelihood of excessive use.

CONCLUSIONS

Despite proven safety issues, inappropriate SABA use is still prevalent. Several factors belonging to patients' characteristics and type/quality of care were associated with inappropriate use of SABAs and can be used to risk-stratify patients for targeted attempts to reduce this preventable cause of adverse asthma outcomes.

The impact of inappropriate use of short acting beta agonists in asthma

BACKGROUND

Inappropriate use of short-acting beta-agonists (SABA) has been associated with increased morbidity and mortality in asthma. However, the extent and pattern of SABA use have changed significantly over recent years. The outcomes in patients who are contemporarily receiving inappropriate doses of SABA have not been evaluated.

METHODS

We used population-based administrative health data from British Columbia (BC), Canada, to create a cohort of asthma patients aged 14 to 55. The exposure of interest was inappropriate use of SABA with any given 12-month period, as defined and validated previously. The primary outcome was asthma-related hospitalization in the following three-month period; secondary outcomes were asthma-related emergency department (ED) visits, asthma-related intensive care unit (ICU) admissions, and asthma-attributable costs.

RESULTS

A total of 343,520 individuals contributed 2,127,592 patient-years of follow up. Of these, in 190,546 patient-years (7.7%) SABAs were used inappropriately. Inappropriate use of SABAs in any given year was associated with a 45% (odds ratio (OR) = 1.45, 95%CI 1.26-1.66) increase in the risk of asthma-related admissions in the following three-month period. Similarly, inappropriate use of SABA was associated with 25% (OR = 1.25, 95% CI 1.18-1.33) increase in the risk of asthma-related ED visits. The association with ICU admissions was not statistically significant. Inappropriate use of SABA was associated with a 6% (relative rate [RR] = 1.06, 95% CI = 1.04-1.08) increase in total-asthma-related costs.

CONCLUSIONS

Inappropriate use of SABA continues to be problematic in a significant minority of asthma patients and is associated with an increased health care utilization and risk of adverse outcomes.

Quality of asthma care under different primary care models in Canada: a population-based study

Background

Previous research has shown variations in quality of care and patient outcomes under different primary care models. The objective of this study was to use previously validated, evidence-based performance indicators to measure quality of asthma care over time and to compare quality of care between different primary care models.

Methods

Data were obtained for years 2006 to 2010 from the Ontario Asthma Surveillance Information System, which uses health administrative databases to track individuals with asthma living in the province of Ontario, Canada. Individuals with asthma (n=1,813,922) were divided into groups based on the practice model of their primary care provider (i.e., fee-for-service, blended fee-for-service, blended capitation). Quality of asthma care was measured using six validated, evidence-based asthma care performance indicators.

Results

All of the asthma performance indicators improved over time within each of the primary care models. Compared to the traditional fee-for-service model, the blended fee-for-service and blended capitation models had higher use of spirometry for asthma diagnosis and monitoring, higher rates of inhaled corticosteroid prescription, and lower outpatient claims. Emergency department visits were lowest in the blended fee-for-service group.

Conclusions

Quality of asthma care improved over time within each of the primary care models. However, the amount by which they improved differed between the models. The newer primary care models (i.e., blended fee-for-service, blended capitation) appear to provide better quality of asthma care compared to the traditional fee-for-service model.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0232-y) contains supplementary material, which is available to authorized users.

Asthma/COPD drugs reflecting disease prevalence, patient adherence and persistence

The aim of this review is to discuss the methodological issues involved in using pharmacy-record databases of drug sales in pharmacoepidemiology and to illustrate the usefulness of such data in estimating disease prevalence, patient adherence and persistence to therapy. Recent studies show that asthma/chronic obstructive pulmonary disease (COPD) prevalence increases with age. The volume of acquired asthma/COPD drugs per patient also increases with age and was approximately 2.5-times higher for patients aged 60-69 years compared with patients aged 20-29 years. Despite this, there is a comparatively low interest in asthma/COPD research involving elderly individuals. Published asthma/COPD-prevalence data and drug-treatment-prevalence data correspond reasonably well. Short- as well as long-term studies on drug acquisition indicate that approximately a third of patients have drugs available to cover at least 80% of the prescribed treatment time. Only approximately a tenth of the patients acquired steroids or steroid combinations, corresponding to one daily defined dose per day over a 5-year treatment period. It is probable that asthma/COPD is undertreated in all age groups.

Association between prescribing patterns of anti-asthmatic drugs and clinically uncontrolled asthma: a cross-sectional study

OBJECTIVE

Studies based on prescription data have shown that many asthmatics tend to use large quantities of inhaled beta-2-agonists, suggesting poorly controlled disease. The aim of the present study was to investigate the association between clinically uncontrolled asthma and prescribing patterns of anti-asthmatic drugs with a primary focus on short-acting beta-2-agonists (SABA).

METHODS

In a cross-sectional study 357 subjects, selected by their prescriptions of inhaled beta-2-agonists in Odense Pharmaco-Epidemiological Database, underwent individual clinical assessment including the Asthma Control Questionnaire (ACQ) and spirometry. The associations between uncontrolled asthma (ACQ score ≥ 1.50) and individual anti-asthmatic prescribing were analysed by means of logistic regression.

RESULTS

Clinically uncontrolled asthma was positively associated with SABA use, the association becoming stronger with higher annual quantity of SABA use, odds ratio (OR) 11.1 (95% CI 4.4-28.0) for ≥400 DDD/year. This trend persisted after stratifying for gender, age, and controller treatment. Although subjects using ≥450 DDD/year were all uncontrolled, there was substantial overlap in SABA use between controlled and uncontrolled subjects below this limit. We found no effect modification by age and gender. Use of inhaled corticosteroids protected against uncontrolled asthma, OR 0.51 (95% CI 0.27-0.95).

CONCLUSION

Asthmatics with a high use of SABA frequently have problems with uncontrolled asthma, and users of ICS are protected against uncontrolled asthma. The associations we found were, however, to weak too allow firm conclusions about asthma control for most individual asthma patients.

Direct health care costs associated with asthma in British Columbia

BACKGROUND

A better understanding of health care costs associated with asthma would enable the estimation of the economic burden of this increasingly common disease.

OBJECTIVE

To determine the direct medical costs of asthma-related health care in British Columbia (BC).

METHODS

Administrative health care data from the BC Linked Health Database and PharmaNet database from 1996 to 2000 were analyzed for BC residents five to 55 years of age, including the billing information for physician visits, drug dispensations and hospital discharge records. A unit cost was assigned to physician/emergency department visits, and government reimbursement fees for prescribed medications were applied. The case mix method was used to calculate hospitalization costs. All costs were reported in inflation-adjusted 2006 Canadian dollars.

RESULTS

Asthma resulted in $41,858,610 in annual health care-related costs during the study period ($331 per patient-year). The major cost component was medications, which accounted for 63.9% of total costs, followed by physician visits (18.3%) and hospitalization (17.8%). When broader definitions of asthma-related hospitalizations and physician visits were used, total costs increased to $56,114,574 annually ($444 per patient-year). There was a statistically significant decrease in the annual per patient cost of hospitalizations (P<0.01) over the study period. Asthma was poorly controlled in 63.5% of patients, with this group being responsible for 94% of asthma-related resource use.

CONCLUSION

The economic burden of asthma is significant in BC, with the majority of the cost attributed to poor asthma control. Policy makers should investigate the reason for lack of proper asthma control and adjust their policies accordingly to improve asthma management.

Suboptimal use of inhaled corticosteroids in children with persistent asthma: inadequate prescription, poor drug adherence, or both?

STUDY OBJECTIVE

To assess the use of inhaled corticosteroids in children with persistent asthma, including patients' adherence to these drugs and physicians' prescribing patterns, by using a novel drug adherence measure, the Proportion of Prescribed Days Covered (PPDC).

DESIGN

Retrospective analysis.

DATA SOURCE

Two administrative claims databases in Quebec, Canada.

PATIENTS

Two thousand three hundred fifty-five children aged 5-15 years with persistent asthma who used more than 3 doses/week on average of a short-acting β-agonist during a 12-month period before beginning treatment with inhaled corticosteroids between 1997 and 2005.

MEASUREMENTS AND MAIN RESULTS

The PPDC measure was defined as the total days' supply dispensed divided by the total days' supply prescribed. During the 12-month follow-up period, 20% of the children received only one prescription for inhaled corticosteroids with no prescribed renewals. The mean number of prescriptions (including prescribed renewals) was 5.0, corresponding to only 152 days' supply prescribed. Mean PPDC (drug adherence) was 62.4%. Only 25% of the patients had controlled asthma, based on the use of 3 or fewer doses/week of short-acting β(2)-agonists and absence of moderate-to-severe exacerbations.

CONCLUSION

A large percentage of children with persistent asthma were prescribed intermittent rather than daily inhaled corticosteroids, and patient adherence to these drugs was suboptimal even though children had free access to their drugs. Many of these patients continued to experience poor asthma control. The PPDC adherence measure developed for this study allowed a better understanding of the gap between treatment goals and asthma control.

Quarterly assessment of short-acting beta(2)-adrenergic agonist use as a predictor of subsequent health care use for asthmatic patients in the United States

PURPOSE

An annual time frame for risk assessment may not account for the variable course of asthma. The purpose of this study was to determine whether excessive short-acting beta(2)-adrenergic agonist (SABA) dispensed quarterly was associated with asthma exacerbations in the subsequent quarter.

PATIENTS AND METHODS

This retrospective cohort analysis included 93,604 health plan members aged 6-56 years with >or=2 years of continuous enrollment (2003-2007), an asthma diagnosis, and asthma prescription claims. The amount of SABA dispensed in claims (metered-dose inhaler and nebulized) was converted to canister equivalents (CEs) in the first observation quarter and categorized as 0, 0.5-3, and >or=3 (excessive SABA use). Asthma exacerbation risk (hospitalization, emergency department [ED] visit, or oral corticosteroid [OCS] claim in the subsequent quarter) was assessed using logistic regression. Covariates used in the regression models were age, sex, geographic region, comorbidities, specialist consultation, asthma controller medication use, and asthma severity.

RESULTS

The cohort included 33,951 patients aged 6-17 years (36%) and 59,653 aged 18-56 years (64%); 64% had 0 SABA CE, and 5% had >3 SABA CEs. Compared with 0 CE, excessive SABA use (>3 CEs) was associated with an increased likelihood of hospitalization (adjusted odds ratio [OR]: 3.15, 95% confidence interval [CI]: 1.89-5.27) and an ED/urgent care (UC) visit (adjusted OR: 3.14, 95% CI: 2.32-4.28).

CONCLUSION

The risk of an asthma exacerbation was associated with excessive SABA use in the previous quarter. Assessment of excessive SABA dispensed during a calendar quarter can be used to identify patients at increased exacerbation risk in the subsequent quarter.

Persistence with asthma treatment is low in Germany especially for controller medication - a population based study of 483,051 patients

BACKGROUND

The objective of the present analysis was to evaluate treatment patterns and persistence with treatment of an unselected patient population with a diagnosis of asthma.

METHODS

The database of the Bavarian statutory health insurance physician's association (Kassenärztliche Vereinigung) covering 83% of the population was analyzed for an index period from April 2005 to March 2006. Defined daily doses (DDDs) were used to quantify treatment persistence. Results were compared with recent guidelines.

RESULTS

The prevalence of physician diagnosed asthma in Bavaria was 4.8% in females and 4.5% in males; only 61.4% of these patients (of a total of n = 483,051) received any anti-asthmatic pharmacotherapy; 68.3% received medical care from their general practitioner, and 8.3% from a pulmonologist alone. Most patients (65.1%) received no more than 90 DDDs of controller medication in the index period of 365 days, only about 1% received medication for the complete index period. Long- (40.1%) and short-acting beta(2)-agonists (65.6%) were used more frequently than inhaled corticosteroids (ICS). 52.8% of asthma patients were treated in accordance with guidelines.

CONCLUSIONS

Persistence of asthma patients with medical treatment is low, especially for controller medication. The discrepancy between current knowledge, guidelines and clinical practice is substantial and may question the value of current guidelines for the treatment of patients with asthma in ambulatory care. In addition, the results of this study cast doubt on the impact of contemporary treatment on the decline of asthma mortality seen in recent years in Germany.

An evaluation of patients' willingness to trade symptom-free days for asthma-related treatment risks: a discrete choice experiment

BACKGROUND

Not taking treatment preferences into account may lead to patients' inappropriate use of asthma treatments. The objective of this study was to quantify these preferences, in terms of risk-benefits trade-offs, for six asthma treatment attributes using a discrete choice experiment (DCE).

METHODS

Adult asthma patients (n = 157) participated in the study. The custom-designed DCE measured preferences for treatment effectiveness (symptom-free days), potential risk (oral thrush and tremor/heart palpitation), ease of use (frequency of daily administration and number of inhalers required), and cost. A nested logit model was used to determine the relative preferences of each attribute, from which the marginal rates of substitution were calculated. Segmented models were used to test for interactions between cost and treatment benefit with socioeconomic status and medication use.

RESULTS

Relationships between preferences and all attributes were in the hypothesized direction. On average, patients were willing to pay an additional $14 per month to receive one additional symptom-free day, and $26, $79, and $112 monthly to avoid one, two, and three annual episodes of oral thrush, respectively. Income and the magnitude of short-acting beta -agonist use also affected treatment preferences.

CONCLUSIONS

Overall, asthma patients desired treatments that offered more symptom-free days, but they were willing to trade days without symptoms in exchange for a reduction in adverse events and greater convenience.

The validity of generic and condition-specific preference-based instruments: the ability to discriminate asthma control status

OBJECTIVE

A goal of asthma management is to improve the patient's health-related quality of life (HRQL). However, it is unclear whether HRQL instruments can discriminate across asthma control measures. The objective of this study was to evaluate the validity of generic and condition-specific preference-based instruments, in terms of their ability to distinguish asthma control.

METHODS

Asthma patients (n = 157) completed three generic preference-based instruments: the Health Utility Index Mark 3 (HUI-3), the EuroQol (EQ-5D), and the Short Form 6D (SF-6D) and two condition-specific questionnaires: the standardized Asthma Quality of Life Questionnaire (AQLQ(S)) and the Asthma Control Questionnaire (ACQ). The AQLQ(S) scores were converted into the condition-specific preference-based scores: the Asthma Quality of Life Utility Index (AQL-5D).

RESULTS

The preference-based instruments were generally able to discriminate across control measures, such as ACQ scores and magnitude of asthma medication, but were not able to discriminate for self-reported control and severity levels. These instruments also correlated with most control measures (r = 0.32-0.37). Significant relationships between AQL-5D scores and all control variables were observed.

CONCLUSIONS

Overall, the AQL-5D discriminated across all levels of asthma control. The HUI-3, the EQ-5D, and the SF-6D differentiated between the highest and lowest levels of control but could not discriminate between the moderate levels.

Medication persistence among patients with asthma/COPD drugs

OBJECTIVE

To determine medication possession ratio (MPR) of patients with asthma/COPD drugs.

METHOD

Individual patient's volumes of asthma/COPD drugs (ATC-code R03) for 2000-2004 were obtained from a pharmacy record database. For each patient the MPR was calculated as the percentage of the treatment time that the patient had drugs available.

MAIN OUTCOME MEASURE

Medication possession ratio (MPR).

RESULTS

A total of 1,812 patients, 20 years and older, with dispensed asthma/COPD drugs were registered in the database, 928 patients (51%) had acquired drugs less than once per year (68% for 20-29 years old) during the 5-year study. Only 13% of the patients had steroids and steroid combinations available to allow continuous treatment. Eight percent of the patients 20-29 years old had MPR > or = 80% of all the included drugs and 5% when only steroids and steroid combinations were considered. About 25% of the patients had acquired 80% of the total volume of asthma/COPD drugs.

CONCLUSION

The majority of the patients, and particularly those in the youngest age group used asthma/COPD drugs only sporadically. This may indicate undermedication which is likely to have a negative impact on patient outcome.

Are we closing the disparities gap? Small-area analysis of asthma in Chicago

Disparities in asthma outcomes in the Chicago area have been observed between geographic areas and ethnic and socioeconomic groups. As efforts to close this gap have moved beyond the initial characterization of the problem to implementation of concrete programs to address these disparities, objective measures of success are essential. We present a variety of data from the Chicago area to assess whether any improvement in previously reported disparities can be demonstrated. While some process outcomes such as medication usage have improved over time, death from asthma has failed to demonstrate an equivalent improvement. More importantly, the differential in asthma mortality and hospitalization rates between African Americans and European Americans has failed to close in the years following the release of the National Asthma Education and Prevention Program asthma guidelines.

Use of anti-asthmatic medications as a proxy for prevalence of asthma in children and adolescents in Norway: a nationwide prescription database analysis

BACKGROUND AND OBJECTIVE

The validity of using self-reported or parental reported asthma symptoms and/or doctor-diagnosed asthma in the estimation of asthma prevalence among children has been questioned. The aim of this study was to assess the prevalence of dispensed anti-asthmatic medications as a proxy of asthma among children and adolescents aged 0-19 years in Norway.

METHODS

Prescription data on subjects aged 0-19 years receiving at least one prescription for an anti-asthmatic during 2004 were retrieved from the nationwide Norwegian Prescription Database.

RESULTS

Overall, 108,719 (9.1% of the Norwegian population aged 0-19 years) individuals received at least one prescription for medication(s) for obstructive airway diseases. The application of criteria that restricted the study population to those receiving inhaled anti-asthmatic medications and those receiving medications reimbursed by the Norwegian health care system for asthma resulted in the identification of 64,458 (5.4%) individuals (4.6% of girls and 6.2% of boys). The prevalence varied by age, with a maximum in both genders at about 2 years of age (7.0% of girls and 10.1% of boys) and a minimum in girls at about 10 years of age (3.3%) and in boys at about 19 years of age (3.5%). Anti-asthmatic inhalants were more frequently prescribed among boys than among girls during the first 15 years of life. Of the children treated, 75% received inhaled glucocorticoids (ICS) in combination with beta2-agonists, of whom 38% received a fixed combination in one inhaler.

CONCLUSIONS

In 2004, about 1 in 20 Norwegians aged 0-19 years were in need of medical treatment for asthma for at least 3 months, reflecting ongoing and clinically important asthma. A rather high proportion of children received fixed combinations of ICS and long-acting beta2-agonists, which may indicate moderate to severe asthma.

Asthma hospitalizations among US military personnel, 1994 to 2004

BACKGROUND

Acute asthma attacks strike unpredictably and may lead to hospitalization in otherwise healthy individuals. The burden of asthma hospitalization on the US health care system has greatly interested health care workers, many of whom see the incidence of asthma as increasing.

OBJECTIVES

To examine the annual incidence of hospitalization and the frequency of subsequent hospitalization for asthma among all active-duty US military personnel between 1994 and 2004 and to determine demographic and occupational risk factors of asthma hospitalization within this generally healthy US population.

METHODS

Annual demographic and occupational data were combined with electronic hospitalization records for patients with a discharge diagnosis of asthma. Using Cox proportional hazard modeling, the authors investigated demographic and occupational risk factors for asthma hospitalization.

RESULTS

Women, married persons, health care workers, enlisted personnel, US Army personnel, and older persons were found to have a significantly greater risk of asthma hospitalization. Yearly rates of hospitalization declined from 22.3 per 100,000 persons to 12.6 per 100,000 persons between 1994 and 2004.

CONCLUSIONS

Although these data have some limitations, they suggest that the burden of asthma hospitalizations in the large, healthy population of US military personnel has declined during the last decade. The decrease in hospitalization potentially reflects improved outpatient management strategies.

Use of nebulized inhaled corticosteroids among older adult patients: an assessment of outcomes

BACKGROUND

Inhaled corticosteroids (ICSs) are used by patients of all ages, but older patients may have difficulty with conventional inhalation devices and therefore may benefit from the easy-to-use delivery mechanism of the nebulizer.

OBJECTIVE

To compare the outcomes, resource use, and health care costs of patients prescribed nebulized ICSs before and after treatment.

METHODS

All patients 50 years and older prescribed nebulized ICSs were identified from a nationally representative managed care claims database (1999-2003). Patients with 1 year of continuous enrollment were analyzed using a retrospective cohort design; outcomes, resource use, and costs were measured and compared 6 months before and 6 months after the initial nebulized ICS prescription.

RESULTS

A total of 2,178 patients were identified for participation in the study, of whom 668 were analyzed. Patients were prescribed nebulized ICSs primarily for asthma (57.4%) and chronic obstructive pulmonary disease (52.1%). Nebulized ICSs were prescribed mostly by primary care physicians and pulmonologists. More than 40% of patients used nebulized ICSs persistently (at least 1 refill); persistent users averaged 123.4 days of use during 6 months of follow-up. There was a significant decrease in systemic corticosteroid use among persistent users (48.0% vs 38.8%; odds ratio, 0.7; 95% confidence interval, 0.5-1.0; P = .03). There was an emergency department visit in 20.2% and 15.0% of persistent users before and after the index date, respectively (odds ratio, 0.7; 95% confidence interval, 0.45-1.09; P = .12); 20.5% and 17.5% were hospitalized before and after the index date, respectively (odds ratio, 0.8; 95% confidence interval, 0.54-1.27; P = .38). No significant difference occurred in total health care costs during follow-up compared with baseline.

CONCLUSIONS

In this retrospective cohort study, older patients who used nebulized ICSs persistently demonstrated fewer emergency department visits and systemic corticosteroid use than before nebulized ICS use. These improved outcomes were not associated with an increase in health care costs.

Socioeconomic status and medication prescription patterns in pediatric asthma in Canada

PURPOSE

To investigate whether the socioeconomic status of children and adolescents with asthma is associated with optimal use of asthma medications in a health care system that provides free access to prescribed medications.

METHODS

A cohort of 29,018 children (5-12 y) and adolescents (13-17 y) with asthma was reconstructed from the administrative health database of the Régie de l'assurance maladie du Québec in Canada. Adherence to the Canadian Asthma Guidelines was compared between low-income patients (patients living in families receiving social assistance) and higher-income patients (patients living in middle-class families with working parents). Both groups of patients had free, universal access to medical care and prescribed medications. Patients were considered adherent if they had: (1) 10 doses or fewer of a short-acting beta2-agonist (SABA) per week or (2) greater than 10 doses of a SABA per week plus greater than 1,000 microg of beclomethasone chlorofluorocarbon (CFC) per day. A second definition of adherence was used in which the 10 doses of SABA were replaced by 3 doses.

RESULTS

Our cohort comprised 7,454 adolescents and 21,564 children. Within each definition, low-income adolescents had similar rates of adherence as higher-income adolescents (p = .08-.4). Low-income children, however, had lower rates of adherence than higher-income children when the first definition of adherence was used (76% vs. 80%; p < .001).

CONCLUSION

Our study showed that socioeconomic status had a small influence on the likelihood of receiving treatment in adherence with the Canadian Asthma Guidelines among children, whereas no association was detected among adolescents.

Should patients with persistent severe asthma be monitored for medication adherence?

BACKGROUND

Poor asthma outcomes often result from patients not following physician medication recommendations (ie, nonadherence). Estimates suggest that 50% of patients with asthma do not follow physician medication recommendations.

OBJECTIVE

To examine the rationale for making available objective medication adherence monitors for physicians to improve the quality of care for patients with severe persistent asthma.

METHODS

Review of the literature was undertaken in the following areas related to asthma: cost, morbidity, adherence, adherence monitoring, outcomes, and guidelines.

RESULTS

Patients with severe asthma are at risk for nonadherence because of (1) the use of multiple medications to control symptoms, (2) coexisting disease states, (3) the occurrence of depression and anxiety, and (4) the high cost of care. Research studies have demonstrated the effectiveness of objective monitoring as part of multiple clinical strategies to improve adherence and reduce morbidity and the cost of asthma care. Without objective adherence monitoring, physicians may not accurately assess nonadherence as the cause of treatment failure. This may lead to inappropriate increases in therapy, diagnostic studies, and consultations and may leave the patient at risk for persistent symptoms, morbidity, and death.

CONCLUSION

By correctly assessing nonadherence as the cause of treatment failure in patients with not only severe asthma but mild and moderate disease as well, practicing physicians may improve the quality of care provided.

Reconcilable differences: a cross-sectional study of the relationship between socioeconomic status and the magnitude of short-acting beta-agonist use in asthma

STUDY OBJECTIVE

To assess the association between socioeconomic status (SES) and short-acting (SA) beta-agonist use, controlling for asthma severity.

DESIGN

Cross-sectional study.

SETTING

Vancouver, BC, Canada.

PARTICIPANTS

Two hundred two asthmatics between 19 years and 50 years of age and residing in the greater Vancouver regional district.

MEASUREMENTS

The quantity of SA beta-agonist used in the previous year was collected by self-report; pulmonary function and beta-receptor genotype were measured on each participant. SES was measured at both the individual and population levels. Five methods of adjustment for asthma severity were used, as follows: the Canadian Asthma Consensus Guidelines, three previously developed asthma-severity scores, and forward stepwise multiple regression modeling. Polychotomous logistic regression was used to assess all relationships.

RESULTS

Independent of the method used to measure SES or adjust for asthma severity, lower SES was consistently and significantly associated with the use of greater amounts of SA beta-agonist. Adjusting for severity using the multivariate model explained the most variance of SA beta-agonist use (R(2) adjusted, 0.35 to 0.37). In this model, social assistance recipients were more likely to use greater amounts of SA beta-agonist (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.7 to 6.5). An inverse relationship between SA beta-agonist use and both annual household income (> $50,000; OR, 0.28; 95% CI, 0.13 to 0.60; and $20,000 to $50,000; OR, 0.44; 95% CI, 0.21 to 0.96; relative to <$20,000) and education (completing a bachelor's degree vs no formal education; OR, 0.25; 95% CI, 0.14 to 0.71). Participants living in a neighborhood with higher median household income (OR, 0.91; 95% CI, 0.84 to 0.98 per $1,000 increase) or a higher prevalence of having attained a bachelor's degree (OR, 0.96; 95% CI, 0.84 to 0.98 per 1% increase) were also less likely use greater amounts of SA beta-agonist. Results were consistent for neighborhood unemployment rate.

CONCLUSIONS

The social gradient in asthma-related outcomes may be at least partially attributable to poorer asthma control in lower-SES asthmatics.

Using administrative healthcare data to recruit study subjects: experience with 'camouflaged sampling'

PURPOSE

To recruit a sample of asthmatics heterogeneous for short-acting (SA) beta-agonist use while protecting their privacy, and to compare participants recruited via 'camouflaged sampling' to those recruited through media advertising.

METHODS

Direct and indirect patient contact using camouflaged sampling was used to recruit a stratified random sample of asthmatics, identified based on their receipt of a prescription for a SA beta-agonist. Volunteers were recruited through media advertising. Recruitment rates were determined for both indirect and direct patient contact, and sampled participants were compared to volunteers recruited through media advertising for differences in SA beta-agonist use, demographic socioeconomic factors, and pulmonary function.

RESULTS

109 and 93 participants were recruited through camouflaged sampling and media advertising, respectively. Direct and indirect patient contact resulted in recruitment rates of 5 and 9%, respectively. Sampled participants were more heterogeneous for SA beta-agonist use, older, more likely to smoke or receive social assistance, and of lower socioeconomic status (SES) than volunteers. There was no difference in the association between SES and the magnitude of SA beta-agonist use between recruiting methods.

CONCLUSIONS

Although recruitment rates were lower than anticipated, camouflaged sampling facilitated stratified sampling of a targeted population and resulted in a more heterogeneous sample while protecting patient privacy.